Case 167 -- Bloody Vaginal Discharge

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PATIENT HISTORY:

83 year old female with bloody vaginal discharge. Physical examination revealed a 1.5-2.0 cm pigmented lesion in the vagina. No history of melanoma in the past.

CYTOLOGIC FEATURES ON PAP SMEAR:

Pap smear shows isolated and loosely cohesive groups of epithelioid, pleomorphic cells against a bloody background ( Images 01 and 02). Bi- and multinucleated cells are present (Image 03). The binucleated cells show double mirror image nuclei with prominent nucleoli (Image 04). Some of the tumor cells show intracytoplasmic and intranuclear inclusions. The epithelioid cells show round and eccentric nuclei with irregular contours, prominent nucleoli and coarsely granular chromatin (Image 05). Some of the cells contain extracytoplasmic and intracytoplasmic inclusions. The abundant granular cytoplasm contains brown pigment consistent with melanin in some of the cells (Image 06).

BIOPSY FINDINGS:

Histologically, there is a roughly circumscribed, focally pigmented subepithelial lesion (Image 07). Focally, the overlying epithelium shows junctional activity (Image 08) by atypical melanocytes. The rest of the surface epithelium is eroded. The majority of the lesion is subepithelial characterized by proliferation of the melanocytes (Image 09) in sheets and nests supported by a delicate fibrovascular stroma. Intranuclear and intracytoplasmic inclusions are present in some of the cells. Most of the cells are epithelioid, occasionally spindled, with large irregular nuclei, prominent nucleoli and coarsely granular chromatin. Brown cytoplasmic pigment (Image 10) consistent with melanin is present in some of the tumor cells and within melanophages.